Monday, October 31, 2016

Happy Halloween everyone! Please don't dress up as a psychiatric patient, it's not funny, and depicting people with illnesses in harsh ways is...harsh and insensitive, promoting stigma and fear.In addition to Halloween --and yes there will be candy at my house tonight --- tomorrow, November 1st, is the official publication date of our new book, Committed : The Battle Over Involuntary Psychiatric Care. The printer got a little excited and released the books to Amazon (and maybe some libraries) a bit early, but our hard-working publicist, Gene Taft, at the Johns Hopkins University Press has been trying to keep things under wrap and he's done a fine job.

As the publication date has approached, there have been some reviews, and I'd like to list them in one place.

I just finished this book, written by two people I am proud
to call friends and colleagues, and one which highlights and tells the
story of many of my other friends and colleagues, on all sides of the
issue that the book covers. It is a marvel of balance and completeness,
and of shared ideas and vigorous debate regarding differences in
opinion. In a world that seems to be becoming increasingly polarized, this book is an object lesson in how to discuss contentious issues while still getting along.
None of us has a monopoly on "the truth" because in the area of
involuntary treatment, there is no single, unitary "truth." I recall
struggling as a psychiatry resident with issues of autonomy versus my
rudimentary ideas about what would be "best" for a patient. I recall
losing sleep - for patients I let go, and also, differently, and over a
much, much longer term, for patients I may have wrongly retained.
This book forces the reader to confront issues related to
self-direction, to the adverse impact of mental illness on
decision-making, to the battles being fought over where the line is that
should legally permit the involuntary treatment of a person who does
not want it. Buy it, and read it. You will learn much, and perhaps, just perhaps, get a sense of where the "other side" is coming from.

Updating on 11/1/16: a Wonderful review on Pete Earley's blog:"While books of this nature often are text book boring, COMMITTED is not. One reviewer credited the “care and consideration” that went into the book for its readability."I'll add more as reviews come in, and on Thursday I'm going to write a bit about the process that went into writing this book in a post for the Johns Hopkins University Press blog, which I'll post over here as well. Before I even do that, I do need to thank so many of our readers, both here and at Clinical Psychiatry News, who first made us aware of what a troublesome and complicated issue forced care is, and who opened themselves us to telling us their stories and sharing such painful parts of their lives with us. You know who you are, and thank you so much. If you were an integral part to the book, a copy was sent to you with the pre-release batch weeks ago.

So if you're interested, Amazon is happy to sell a good quality, hard copy of of our book, representing many years of work by two psychiatrists for the low price of $15, or $12.99 on kindle.

More soon, I'm just sharing my excitement. More fun than thinking about Anthony Weiner's laptop and the upcoming election.

Saturday, October 22, 2016

So often I write blog posts about topics I read about in the paper. I take a few quotes and expand upon them. Today I want to look at book review by Dr. Damon Tweedy, a psychiatrist at Duke University and author of Black Man in a White Coat: A Doctor's Reflection on Race and Medicine. Only this is a little different. Dr. Tweedy is reviewing a book that We wrote! And a fine job he did, if I do say so myself.

Here, they explore forced psychiatric care, perhaps the most polarizing
aspect of a controversial profession. The result is a highly informative
and surprisingly balanced book that should be read by anyone with a
personal or professional stake in how the mental health system provides
care to those with chronic severe illnesses and those in acute crisis.

Miller and Hanson take us on a journey across America, where we witness
significant variability in how states approach the issue of forced care.
In some states, patients must be deemed imminently dangerous to
themselves or others (i.e. high risk for suicide or homicide) for forced
treatment, while in other states an inability to provide for basic
needs due to mental illness is sufficient. The process of commitment
also differs. California, for instance, does not require a formal
psychiatric evaluation before patients can be involuntarily admitted to a
psychiatric hospital, while in Maryland an evaluation must be done
before admission and requires the input of two physicians or
psychologists. Until recently, doctors in Virginia could not use the
input of family members in assessing a person’s potential dangerousness. And finally:

Although “Committed” explores a complex subject, Miller and Hanson make a
great effort to humanize this discussion. In each section, they
introduce us to individuals — patients, family members, advocates,
lawmakers, emergency-room doctors, psychiatrists, police officers and
judges — involved in some aspect of forced treatment.Thank you, Dr. Tweedy!

Thursday, October 20, 2016

Ah, technology. The Scattergood Foundation is having an all day conference on Ethics and Correctional Mental Health today in Philadelphia. No the conference is not free, but I imagine there will be time to get a cheesesteak (whiz, please) and if you've lived in Philly, you'll understand the reference to Cheese Whiz. The Conference is being lived streamed, so you want to learn about ethics and mental health care in our jails and prisons, do consider attending, in your pajamas if you'd like. Here is the information:

Sunday, October 09, 2016

When I was in high school, one of my friends got mono -- infectious mononeucleosis or kissing disease. He had a minor sore throat and, because his girlfriend was quite sick with mono, he went to the doctor and was tested. He tested positive, but unlike his girlfriend, he never got sick and said, "Well, I haven't tried to run a mile, but I'm pretty sure I could." Still, there is no doubt that both young people had been infected with the virus and one got sick while one did not.

One of the things I learned from the extensive research we did for our forthcoming book, Committed: The Battle Over Involuntary Psychiatric Care is that not every has the same experience of the same illness or the same treatments. Okay, I didn't have to write a book to tell you that, I see it in my office every single day with every single patient. Why does one person get a severe tremor to Wellbutrin while another with similar symptoms just gets better with no side effects? Why do some people need psychotherapy while others get better from a pill? Clearly psychotropic medications don't agree with some people, and clearly they don't make everyone with psychiatric illness all better, but there is a contingency of people who feel that since medications were for bad for them, they are bad for everyone. They are wrong. I wrote a blog post about a NY Times op-ed piece last week called "Medicating a Prophet" by Penn psychiatrist Irene Hurford. She works with young people with psychosis, and I'm going to guess that she seen patients with a range of experiences. In her op-ed piece, Dr. Hurford makes the point that there are people who like their psychotic symptoms, who gain some comfort from them, and who suffer when they lose their delusions and get smacked with the awful reality of their illness. She doesn't say that there are not patients who are tormented by their psychosis and I'm going to make the assumption that she has met many paranoid, uncomfortable, and suffering patients -- psychosis is not fun for most people. Dr. Hurford further makes the point that forced care can be traumatic-- and, as we write in Committed, it can be for some people, even if it is appreciated by others. I read from her article not that psychosis never leads to violence, but that rare, extreme acts of violence are rate and extreme and shouldn't be what sets public policy. She is not the only psychiatrist I know of who is not gung-ho on making forced care easy policy, and I know several forensic psychiatrists who work with the most violent of patients on a daily basis, and still don't see involuntary treatment as the way to prevent these acts.

The New York Times recently ran an op-ed declaring that being
psychotic is “enriching,” and arguing against involuntary treatment of
the psychotic. “The assumption that someone else’s reality is invalid
can foster distrust; it sends the message that we don’t respect this
person’s experience of his or her own life,” wrote
Irene Hurford, an assistant professor of psychiatry at the University
of Pennsylvania. This romantic, Pollyannaish, and false view of
psychosis is rampant in the mental-health system, regularly parroted by
the media, and dangerous to both patients and public.

Jaffe goes on to talk about people with psychosis who have killed, and how assisted outpatient treatment can be live-saving. He talks about how nurses who treat psychiatric patients have emergency buttons, but those who treat psoriasis don't. Well, there are several cases, at Harvard and at Johns Hopkins, where surgeons have been shot by disgruntled family members. Maybe everyone needs emergency buttons.

I want to borrow these articles to make the point that there is no single reality. Some patients find their psychotic symptoms to be tormenting. Some may find their private reality to be enriching, especially during a mania. Some patients with psychiatric disorders are dangerous. Some people get in cars after they've been drinking or using drugs and are dangerous. And some people are just angry and dangerous. Please, let's not assume that the experience or the needs of all people with mental disorders are the same. And let's not even assume that psychiatrists are the same -- some are quicker to prescribe, and some are quicker to commit patients to hospitals. Often studies of violence outcome look at acts like slamming doors or shoving someone. While I have no doubt that psychiatric treatment, especially treatment done with with the doctor on the same team with the patient, saves or at least enriches lives, there is no evidence beyond the anecdotal that forced outpatient care prevents murders, mass murders, or even suicide, or that other, more collaborative methods might be more effective.

And please, don't even consider reading this and thinking that I believe there aren't situations where the only option is to force a very sick patient to get involuntary care. I just don't think we should assume all people with psychotic disorders have the same experience.

Tuesday, October 04, 2016

For years -- over 10 to be a bit more exact-- we've had controversy here at Shrink Rap when we've talked about forced psychiatric care. It's a controversial topic not just for patients -- some who have benefited from it and some who feel injured by it, but also for psychiatrists who vary in their own views about civil liberties and medical paternalism. Ah, as I'm sure our regular readers know, it inspired us to write a book, Committed: The Battle Over Involuntary Psychiatric Care, and I do hope you'll read it.

I was pleased to read "Medicating a Prophet," in this past Sunday's New York Times. Psychiatrist Irene Hurford adds to the idea that there is not a single truth about involuntary treatment as good or bad, and that this is a complex topic where there may be more than one reality. Dr. Hurford writes:

Proponents
of enforced treatment often point to horrific but rare events, like
mass shootings, committed by people with mental illness. But psychosis
alone is only a modest risk factor for violence. A 2009 study
of more than 8,000 people with schizophrenia found that those who did
not abuse drugs or alcohol were only slightly more likely than the
general population to be violent.

There
are several studies that demonstrate that assisted outpatient treatment
can reduce the risk of hospitalization, arrest, crime, victimization
and violence. Few, however, are based on high-quality randomized
controlled trials. A 2014 meta-analysis
of three randomized-controlled studies of more than 700 people found no
statistically significant benefit of enforced outpatient care in
reducing hospitalizations, arrests, homelessness or improving quality of
life.

It
can be devastating for families and doctors alike to watch psychosis
seemingly claim the lives of those we love or care for. And in some
situations, brief episodes of enforced inpatient or outpatient treatment
may be necessary. But in my experience, weeklong inpatient stays, or
yearlong outpatient treatment regimens, can do more harm than good when
they engender distrust. Perhaps we must accept a new reality — to truly
engage people in treatment we need to understand their own experience of
psychosis and its treatment.